累及血管神经的软组织肉瘤患者的不同外科治疗方法探讨

Surgical treatment for soft tissue sarcoma involving vascular nerves

目的探讨累及血管神经的软组织肉瘤外科治疗方法,提出肿瘤累及血管神经程度的分类。方法行回顾分析2016年12月至2021年12月,我院收治的48例软组织肉瘤患者的临床资料。所有患者术前均行MRI检查,并对解剖结构复杂的患者行局部增强CT,根据肿瘤与血管神经的关系制订了3种手术方案:肿瘤与血管神经接触面周长的角度≥180°(A型),相应的血管做人工血管置换或血管移植,相应的神经切除;肿瘤与血管神经接触面周长的角度<180°(B型),手术将相应的血管神经外膜完整剥离,保留主干;血管神经远离肿瘤(C型),手术完整切除肿瘤,保留血管神经外膜。结果48例均获得边缘阴性(R0)切除,A型7例(14.6%)行人工血管置换术或神经血管切除术。B型9例(18.8%)行血管神经外膜剥离术。C型患者32例(66.6%),行肿瘤完全切除,血管神经结构完整。B型局部复发率22.2%,C型局部复发率21.9%,B型和C型局部无复发病例的生存时间差异无统计学意义(P=0.958),B型血管神经的外膜剥离手术对疾病术后的局部复发无影响。结论在肿瘤“累及”血管神经的患者中,肿瘤与血管神经接触周长的角度<180°时,血管神经切除的程度对疾病局部复发或存活率没有显著影响,此手术方案是安全可行的。因此,“累及”血管神经的精确分类可能有助于选择适当的切除程度,而不会影响肿瘤结果或不必要地牺牲功能。

Objective To evaluate the surgical treatment of soft tissue sarcoma involving blood vessels and nerves,and to put forward the classification of vascular and nerve involvement.Methods A retrospective analysis was performed on the clinical data of 48 patients with soft tissue sarcomas adjacent to or involving blood vessels and nerves in the First Affiliated Hospital of Xinjiang Medical University from December 2016 to December 2021.All patients were examined by MRI before operation,and patients with complex anatomical structure by local enhanced CT.According to the relationship between the tumor and the blood vessels and nerves,three surgical schemes were made.Type A:The adventitia of the corresponding vessel and nerve was completely stripped off and the trunk was preserved;the angle of the perimeter of the interface between the tumor and the blood vessels and nerves was≥180°.Type B:The angle of the perimeter of the interface between the tumor and the blood vessels and nerves was less than 180°.Type C:The tumor was surgically removed and the vascular nerve membrane was preserved;corresponding blood vessels were replaced by artificial blood vessels or vascular grafts.Results All 48 patients had negative margin(R0)resection,including 7 type A patients(14.6%)with artificial vascular replacement or neuroangiectomy,9 type B patients(18.8%)with vascular epineurium dissection,and 32 type C patients(66.6%)with complete tumor resection and intact vascular nerve structure.The local recurrence rate of type B was 22.2%,while type C 21.9%with no statistical differences in local recurrence-free survival time between type B and type C(P=0.958).Type B adventitial dissection surgery had no effect on postoperative local recurrence of the disease.Conclusions It is confirmed that the degree of vascular and nerve resection has no significant effect on the local recurrence or survival rate for tumor patients when the angle of the perimeter of the interface between the tumor and the blood vessels and nerves was less than 180°.Therefore,the precise classification of involved vessels and nerves may help to select the appropriate degree of resection without affecting the outcome.